Sept. 27--It's not unreasonable to view the five-candidate scrum for three seats on the Marin Healthcare District board in the Nov. 6 election as a referendum on the management of Marin General Hospital, Marin's largest hospital.

Three of the candidates -- Dr. Larry Bedard, Jennifer Rienks and Dr. Brian Su -- are closely aligned with the current management and seem largely satisfied with the status quo. The other two candidates -- Dr. Edward Alfrey and Melissa Bradley, owner and founder of Bradley Real Estate -- are more critical.

For years, healthcare district board races were referendums on Sutter Health's management of Marin General. Bedard, who worked in Marin General's emergency department from 1979 to 2001, originally served on the district board from 1992 to 1996.

Sutter Health leased Marin General in 1996. Bedard backed Sutter Health at that time and argued against returning management of the publicly owned hospital to district management out of fear that it wouldn't be able to compete as a stand-alone hospital.

Bedard was re-elected to the board in 2006 and has served since then. Rienks, associate director of the Family Health Outcomes Project for the University of California, San Francisco, has also served on the board since 2006, but she and Bedard were polar opposites on the question of district management of the hospital.

After the district regained control of Marin General in 2010, Bedard and Rienks forged a working relationship and have rarely differed on issues facing the hospital, including formation of a separate board of directors to oversee the day-to-day operations of Marin General.

Su, a spine surgeon who began practicing in Marin 10 years ago, said he decided to run for the board after Bedard and Rienks urged him to join them to run as part of a slate. At the time, no one else had expressed an interest, and it appeared the three might run unopposed. Su serves on the lease and building committee for the healthcare district board and on the patient safety committee for the separate hospital operating board.

Alfrey, also a surgeon, serves as the medical director of trauma at Marin General, chairman of the hospital's Department of Surgery, and board chairman of the Prima Medical Group, which provides office space, staff, high-tech equipment and financial incentives to attract young doctors to Marin.

"One of the big problems that we have in our emergency department, as we have all over the country, is overcrowding. I know it has been an issue on the healthcare district board's agenda five times in the last 12 meetings," Alfrey said.

Alfrey said such overcrowding can result in patients being boarded in the emergency department, which can lead to adverse patient outcomes.

As for the two-tiered management structure, Alfrey said, "I'm a little unclear about what influence the healthcare district board has over the hospital board. I know what it says in principle, but I don't quite get that relationship."

And, Alfrey said, "One of the major concerns that the hospital staff has had with the administration is communication. I don't think any administrator would say they were surprised to hear that because we've talked about it continually."

Bradley said she has become interested in civic engagement since recovering from acute emotional distress precipitated by a divorce and a child custody battle.

Commenting on a grand jury report on mental health care in Marin jails during a June meeting of the Marin County Board of Supervisors, Bradley said that after suffering a breakdown she was placed in a cell reserved for inmates with mental illness.

"There was not a psychiatrist there," Bradley told supervisors. "There was a nurse. She did not do a sufficient job of assessing the situation."

Bradley said Marin General's emergency room lacks a full-time psychiatrist and the new hospital wing under construction will have an insufficient number of beds for patients needing psychiatric care.

Bradley says she is the only candidate who is not part of the medical community and would help to broaden the board's perspective.

"The board is made up of all medical professionals," Bradley said. "So for oversight to happen you really need somebody who is not directly getting compensated or contracting in any way with Marin General Hospital, the clinics or UCSF. It's good to have a variety of opinions."

Bedard and Rienks say they want to remain on the board to oversee the opening of the new Marin General Hospital wing, scheduled for 2020, and the hospital's newly announced strategic alliance with UCSF.

While Alfrey and Bradley emphasize the internal changes they would like to see implemented at Marin General, Bedard and Rienks speak about the larger challenges facing the hospital from external forces.

"I think one of the keys to Marin General's future success is our relationship and partnership with UCSF," Bedard said.

"I've talked at San Francisco Marin Medical Society meetings about how we can integrate the medical staffs," said Bedard, who served as president of the Marin Medical Society before it merged with San Francisco Medical Society in 2017.

"At Marin General, we have one of the oldest medical staffs of any hospital in California, and it is hard to recruit doctors to come here," Bedard said.

Rienks said, "A lot of hospitals and health care businesses across the country are facing rising costs. Too often those costs are being passed on to consumers. We have to do something to contain costs because consumers can't afford what health care is costing them even if they have insurance.

"We really need to look at how we keep the population healthy," Rienks said, "and how we can move services into lower-cost environments."

The survival of many hospitals is threatened by shrinking reimbursements, Rienks said. She said in this environment bringing clinical expertise to Marin General is vital.

"That is why the merger with UCSF is so important," she said.

Bedard also noted that under the strategic alliance UCSF will assist Marin General with the installation of the EPIC electronic medical record system. Both doctors and nurses have struggled with the hospital's existing medical record system.

Although aligned with Bedard and Rienks, Su shares some of the concerns expressed by Alfrey and Bradley.

"I think the leadership does a good job, but I think there needs to be more physician engagement," Su said. "Management and the physicians need to be a little bit more closely aligned."

Su said the strategic alliance with UCSF "could be a very good thing, but I think it needs to be done carefully and correctly."

He said he doesn't want to see UCSF "cannibalize" Marin physicians' practices.

And, Su said, "The board needs somebody who is in the trenches but also not financially tied to the hospital."

Reason for running: "I am committed to ensuring that Marin General Hospital provides world-class care and that all residents of Marin have access to that care. Marin deserves someone on the Healthcare District Board who is not financially tied to the hospital, is familiar with the inner workings of the hospital, and has experience working with all three boards (operating, district, and foundation).

Jennifer Rienks

Age: 53

Residence: Fairfax

Education: bachelors in psychology from University of Connecticut and doctorate in social psychology from University of California, Santa Cruz.

Occupation: Public health researcher, University of California, San Francisco.

Experience: Twenty-two years, UCSF Department of Family and Community Medicine. Associate Director of the Family Health Outcomes Project, leading research and training public health staff on monitoring and improving maternal, adolescent, and child health. First elected to the Healthcare District Board in 2006.

Reasons for running: to ensure the rebuilding of Marin General Hospital into a state of the art, environmentally-friendly "green" hospital stays on track and on budget to open in 2020; maintaining and increasing access to primary care, and improving community health; supporting and expanding mental health programs.

Dr. Edward Alfrey

Age: 64

Residence: San Rafael

Education: BA, University of Denver, 1972-1976; paramedic, city and county of Denver, 1976-1980; MD, University of Colorado, 1980-1984; residency in surgery, University of Arizona, 1984-1989; fellowship in transplantation, University of Pennsylvania, 1989-1991; Master's degree in health care management, Harvard University, 2003-2005.

Experience: Awarded the Legacy Award from Operation Access for service to the uninsured; director for the Surgery Student Clerkship at Stanford University; Chief of Transplantation at Penn State University and Southern Illinois University; member of faculty senate at Stanford University; Chair of General Surgery and Residency Program Director for Surgery at SIU.

Reason for running: To help shape the future of Marin health care during a time of tremendous transition, through my extensive experience in health care. One area where we can improve health care in the county is to reduce the overcrowding at MGH in the Emergency Department, which leads to poor patient satisfaction scores. I would focus on flow through the hospital as one solution and increasing patient access to the Marin Community Clinics as another solution.

Larry Bedard

Age: 74

Residence: Sausalito

Education: 1966 Bachelor of Science, University of Michigan; 1970 medical degree, University of Michigan Medical School; 1970-1971 internship, French Hospital, San Francisco; 1971-1072 psychiatric residency, University of Michigan.

Experience: Marin Healthcare District, board member 1992-1996, 2006-present. Former president of the Marin Medical Society and California chapter of the American College of Emergency Physicians. Worked for the passage of the Emergency Medicine Treatment and Active Labor Act in 1986 and the 1989 amendments that established the legal right of all people to receive emergency care.

Reason for Running: Seeking my fifth and last term on the Marin Healthcare District Board to facilitate the completion of the new on-time and on-budget state-of-the-art Marin General Hospital in 2020. I believe the implementation of the Epic electronic medical records system will significantly increase patient, nurse and physician satisfaction. We need to assure that the modernization project will stay on time and on budget.

Melissa Bradley

Age:47

Residence: San Rafael

Education: left Sir Francis Drake High School in senior year to marry, later took the GED to receive diploma. Has real estate broker's license.

Occupation: Owner and founder of Bradley Real Estate. Also volunteered for several Marin organizations including Red Cross, Whistlestop and Performing Stars in Marin City.

Experience: Starting and running one of the largest businesses in Marin. Volunteer for Red Cross, Whistlestop and Performing Stars in Marin City.

Reason for running: I want to be involved in our community and make a difference in people's lives. I want to advocate for the things I believe in. I've learned a lot over the last year and a half and I do believe I can participate in making Marin a better place.